As many as 2.3 million adults ages 19 to 24 could lose Medicaid coverage once federal work requirements take hold, according to a new simulation from the Urban Institute, a left-leaning Washington think tank. The estimate, released Monday and reported by Fierce Healthcare, ranges from 1.1 million to 2.3 million depending on how states carry out the rules.
The figure is a model, not a government forecast or a count of people who have already lost coverage. It also does not suggest that young adults are avoiding work. Urban estimates that 88% of young adults in the group already do something that would satisfy the requirement, such as working or attending school.
The concern is paperwork. Young adults tend to move often, sometimes between states, and their gig work or schooling can be harder for states to verify automatically, the analysts said. For a 22-year-old juggling part-time shifts or community college classes, a missed notice could mean losing coverage for prescriptions, mental health care, or an emergency visit.
Inside the Simulation
The work requirement comes from the 2025 budget law often called the One Big Beautiful Bill Act. Most adults ages 19 to 64 who are covered through the Affordable Care Act's Medicaid expansion must show at least 80 hours a month of work, school, job training, or community service, or qualify for an exemption. States must also recheck eligibility for this group every six months instead of once a year.
Urban modeled two broad approaches. In a high-mitigation scenario, where states work actively to prevent coverage losses through tools such as automatic data matching and targeted outreach, enrollment among young adults would fall 9% to 31%. In a low-mitigation scenario, the drop would range from 22% to 58%, Fierce reported.
"The extent of Medicaid coverage drops for this group will depend heavily on state data matching capacity and implementation choices," Jennifer Haley, a principal research associate at the Urban Institute, said in a statement.
The young adult estimate builds on Urban's earlier work. A broader Urban projection for all expansion adults, released in March, found 4.9 million to 10.1 million fewer people enrolled in expansion coverage in an average month of 2028 under the work requirements and six-month eligibility checks combined. That report noted that data matching played a key role in limiting coverage losses under earlier state work requirement programs.
The new young adult report is one scenario-based estimate, and actual losses will depend on choices many states have not finalized.
Competing Forecasts and Local Stakes
Other projections differ in scope and assumptions. In its interim final rule issued in June, the Centers for Medicare and Medicaid Services estimated that roughly 2.3 million people of all ages would lose coverage in fiscal year 2027, MedicalDaily previously reported. That federal figure covers a different population and should not be confused with Urban's young adult range.
The Department of Health and Human Services has argued the policy can help families. A research brief from its Office of the Assistant Secretary for Planning and Evaluation estimated that the requirements could lift 1.6 million to 2.9 million people out of poverty. The analysis assumed no implementation delays, and its higher figure assumed states would face no implementation challenges.
Local exposure depends on where young adults live and on state choices. The requirement applies in the 43 states and the District of Columbia that cover adults through Medicaid expansion or similar waiver programs, so low-income adults in non-expansion states such as Texas and Florida are largely outside this rule. Separately, Urban has estimated that roughly 3 in 10 adults ages 18 to 24 are insured through Medicaid, and young adults have the highest uninsured rate of any age group.
Urban also found that the expiration of enhanced ACA premium tax credits, combined with changes in the 2025 law, will likely leave fewer than 1 million young adults in subsidized ACA plans, limiting a fallback option.
Who faces the greatest burden? Young adults who move between cities or states, work irregular gig or seasonal hours, are self-employed, or attend school are among those most likely to be caught by verification gaps. People managing chronic or mental health conditions could also face disruptions in care if they must document an exemption.
What remains unknown is how each state will run its system. Some states may automatically confirm school enrollment and wages, while others may rely more on manual uploads.
Steps Young Adults Can Take Now
Update your mailing address, phone number, and email with your state Medicaid agency, especially after a move. Notices sent to old addresses are a common reason people miss renewals.
Keep records of pay stubs, gig app earnings statements, school enrollment verification, and volunteer hours. If you believe you qualify for an exemption, such as caring for a child younger than 14 or a disabled family member, or having a serious health condition, ask your state how to document it before your renewal.
Respond to every Medicaid notice by the deadline. If you lose coverage, ask about appeal rights right away. If you take prescription medication, talk with your clinician or pharmacist about a backup plan so treatment is not interrupted. Community health centers offer sliding-scale care for people without coverage.
States must begin enforcing the requirements no later than Jan. 1, 2027, and some, including Nebraska, have moved to start earlier. States that show good-faith compliance efforts can seek exemptions that delay enforcement as late as the end of 2028. Separately, 25 states and the District of Columbia have sued over the federal rule. MedicalDaily will track state rollout plans and any court decisions that change the timeline.
Key Questions Answered
What did the Urban Institute estimate? That 1.1 million to 2.3 million adults ages 19 to 24 could lose Medicaid coverage under work requirements, depending on how states carry them out.
Is this an official government forecast? No. It is a simulation by a nonprofit think tank. CMS has published its own, separate projection covering all ages.
Are most young adults on Medicaid already working or in school? Urban estimates that 88% already take part in an activity that would meet the requirement.
Why would working young adults lose coverage? Mainly because of paperwork and verification problems, such as frequent moves, irregular gig income, or school enrollment that states cannot automatically confirm.
When do the rules start? States must begin by Jan. 1, 2027. Some states, including Nebraska, have moved to start earlier.
Does this apply in every state? No. It applies in the 43 states and the District of Columbia that cover adults through Medicaid expansion or similar waiver programs.
What should young adults do now? Update contact information, save proof of work or school, respond to notices on time, and ask about exemptions and appeals.
